Nursing Care for Gastrointestinal Reflux
Gastroesophageal Reflux Disease
Quality-of-life issues stem from esophageal complaints and other symptoms presented in the primary care setting, including aspiration pneumonia. GERD can result in an overwhelming use of antacids, which often negate the effects of medications used to manage chronic diseases common to older adults ( Meiner , 2003).
Diseases In GERD
GERD includes a wide array of illnesses that stem from the retrograde flow of gastric contents into the esophagus. Symptoms of GERD include globus pharyngitis, chronic cough, asthma, hoarseness, laryngitis, chronic sinusitis, dental erosions, dyspepsia, belching, heartburn, regurgitation, and delayed gastric emptying (Sermon et al., 2004; Lackey & Barth, 2003; Williams, JL, 2003).
The association between GERD and patient's complaints of ear, nose, and throat symptoms has led to several new research. studies that look at the phenomenon while attempting to identify a diagnostic feature (Sermon et al., 2004; Vaezi , Hicks, Abelson, & Richter, 2003).
These studies include an in depth look at dental erosions caused by GERD (Lackey & Barth, 2003; Van Roekel, 2003). Chronic abnormal gastric reflux results in erosive esophagitis in up to 60% of patients diagnosed with GERD.
Esophageal stricture, Barrett's
esophagus, and esophageal adeno carcinoma are the most serious complications of
GERD (Williams, 2003). If unchecked, simple complaints can progress to terminal
illness.
Causes of GERD
Causes of GERD include gastric acid hypersecretion, impaired gastric motility, weakened pressure of the lower esophageal sphincter (LES), transient lower esophageal sphincter relaxations (TLESRS), ineffective esophageal peristalsis, and loss of the integrity of the esophageal mucosa.
Increased gastric volume
after meals, incorrect positioning that allows gastric contents to remain close
to the LES, such as bending over or lying down, and obesity or wearing tight
clothing add to the causes of GERD ( Storr , Meining , & Allescher , 2000
).
GERD Associated Problems
Swallowing abnormalities associated with GERD can cause a complex interaction between the various nerves and muscles with involuntary and voluntary patterns of control and the upper airway ( Mokhlesi , 2003).
These swallowing abnormalities range from dyspepsia to aspiration of esophageal contents resulting in a chronic cough. While the association between GERD and asthma has been previously established ( Mujic & Rao, 1999), the relationship between GERD and chronic obstructive pulmonary disease (COPD) is still being studied due to the complex interactions of symptoms, including the use of bronchodilators .
Data does indicate that the presence of GERD in patients with COPD is higher than in normal populations ( Mokhlesi ). Further study is needed to establish the association between the swallowing dysfunction of GERD and stable and acute episodes of COPD.
A progressive increase in the prevalence of severe erosive esophagitis was observed with each decade of life until greater than 37% of patients over age 70 were identified as being affected (Johnson, DA, & Fennerty , 2004).
These researchers found that heartburn is an unreliable
indicator of the severity of erosive disease among older adults. This led to
the recommendation that more aggressive investigation and treatment may be
needed for older adult patients with or without complaints of heartburn
(Johnson, DA, & Fennerty ).
Diagnosis
Following the recent establishment of international control values for diagnostic (scintigraphy) gastric emptying assessment, an improvement in the ability to diagnose GERD-associated symptoms from the delay.
In gastric emptying can be identified (Buckles, Sarosick, McMillin, & McCallum, 2004). The significance of this research is to identify a subgroup of patients that may have GERD without having the cardinal symptoms, but are at risk for pathophysiology.
The "gold standard" study for confirming or excluding the presence of abnormal gastroesophageal reflux that continues to be used most widely across the US is the 24-hour ambulatory esophageal pH monitoring test ( Szarka , De-Vault, & Murray, 2001).
The best marker for the ability to heal erosive
esophagitis with any drug is the ability to keep the gastric pH above four. The
longer any dose of any drug can keep the pH above four (pH 4), the more likely
it is to heal erosive esophagitis ( Hatlebakk , 2003).
The introduction of fiberoptic instruments and ambulatory devices for continuous monitoring of esophageal pH (24-hour pH monitoring) has led to great improvement in the ability to diagnose reflux disease and reflux associated complications. Treatment options include lifestyle changes, medication, and surgery.
Polypharmacy and changes in renal, hepatic, and gastrointestinal function can complicate treatment. Due to the large number of medications taken by older adults for comorbidities, drug interactions and treatment responses must be carefully assessed in this population (Ramirez, FG, 2000).
Lifestyle changes are the cornerstone for effective patient education and an understanding of GERD treatment. Further nursing research is needed to identify behavior modifications that are more likely to be sustained over time.
Future nursing studies that may produce long-term lifestyle changes will need to include the following elements that are known to reduce GERD:
(a) dietary modifications designed to avoid foods and fluids that lower LES pressure (eg, tomatoes, peppermint, licorice , alcohol, and caffeine-containing foods and drinks such as coffee, tea, chocolate, and colas)
(b) providing a comprehensive history with defining characteristics to the primary health care provider at the onset of ambulatory care
(c) weight loss when obesity is a factor
(d) elevating the head of the bed 4 to 6 inches with blocks (raising the entire angle of the bed); (e) eliminating all food and fluids for the 2 hours before bedtime
(f) smoking cessation
Conclusion
GERD is a chronic problem among many adults. Well controlled trials are beginning to glean information related to successful life- style modifications, improved diagnostic evaluations, and treatment protocols.
Nursing research should be undertaken to study ways of improving adults' willingness to make long-term lifestyle and dietary changes. Studies that investigate symptomatic control may provide the foundation for improvement in the quality of life of patients with GERD.
Studies that identify drugs and foods that increase inappropriate LES relaxation are needed. Obtaining a thorough past history of illnesses, current symptoms, with past and current medication use including over the counter drugs, is a key factor in being able to identify hypotheses for nursing research.
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